The Development of an Interventional Package on "Receptive Vocabulary" For Cochlear Implanted Children.

Objectives Considering the shortage of language intervention protocols which specifically concentrate on cochlear implanted children and considering the importance of timely language intervention in this group of children, the aim of the present study was to develop an interventional package on “receptive vocabulary” for cochlear implanted children. Materials & Methods By reviewing the literature related to language acquisition theories in normal and language disordered children, as well as literature on production of intervention protocols, especially those for language impaired children, and also considering the normal process of language and speech development in normal children, the first draft of the intervention protocol was prepared. Then, the face and content validity of the intervention protocol was assessed by a Delphi team through three rounds and finally approved. Results A language intervention protocol was developed to enhance receptive vocabulary in 12-48 months-old cochlear implanted children, based on cognitive, behavioral and developmental theories. This protocol includes 5 interventional stages: 1-Drilling and Imitation; 2-Modeling; 3-Motor training; 4-Deliberate error correction; 5- Reinstatement and Generalization. Each stage consists of the description of the aims of that stage, a list of techniques, the tools required, the detailed step by step explanation of the intervention, how re-enforcement must take place, and finally the indicators of success which permit to move forward to the next stage. Conclusion The interventional package produced is believed to facilitate language acquisition in cochlear implanted children, according to expert qualitative assessment and approval. Experimental research is required for verification of this assumption.


Introduction
Hearing loss is known as one of the most common etiologies of communication disorders (1). About 0.1% of live births suffer from profound congenital hearing loss. Asia is known as a continent with the largest proportion of hearing deficiencies, with 2.6 hearing impaired children born in every 1000 live births during a year. Annually 4000 hearing impaired newborn infants are born in Iran; yet, no absolute statistics exist in this regard (2,3).
Hearing loss causes the child not to communicate with others simply. It is mostly because of the deaf child's disability to acquire language in a natural trend that a normal child does during the first 2 yr of life (4)(5)(6). Many years ago the only way for deaf children to access sound, was to use hearing aids, while it could not provide severely to profoundly, and profoundly hearing-impaired children with different degrees of auditory stimuli (7). These days cochlear implantation is used as one of the best substitutions for hearing aids in order to help deaf children improve their auditory perception and speech and language acquisition (7,8). Although cochlear implantation facilitates language acquisition especially for children received the device in the critical period of language development, enhancing and promoting language development in cochlear implanted children is highly in need of a systematic language intervention protocol (8).
The history of designing language intervention protocols for language impaired individuals goes back to the 1960s and 1970s. The American speech and hearing association (ASHA) solely has performed more than 100 studies in this regard and has established various language intervention models by studying on autistic children, specific language impaired children and other language disordered groups (9).
Nowadays different language intervention protocols have been developed all over the world. These protocols commonly focus on the necessity of timely language intervention for language impaired children or those at risk of it.
However, they mainly differ in terms of their focus on various aspects of language include syntax, semantic and pragmatic (10,11 encouraging parents for active participation in rehabilitation programs. In spite of their similarities, they differ mainly in that the auditory-oral approach encourages the use of lip-reading and facial expressions, while the auditory-verbal approach is not concerned with visual cues (13,14).
Although each of these different intervention programs has its own positive effects for different target groups, to our knowledge, up to now no study has specifically proposed an educational package to facilitate language acquisition, especially

Materials & Methods
This descriptive study was performed in the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran in two phases of review and qualitative phases.
Moreover, the authors chose to focus on the child's motor development, as well as emphasizing on his correct language behaviors, according to findings of some studies regarding correlation between movements and thought. A child's movement ability promotes his investigation of the surrounding environment which may, in turn, facilitate his learning process (17,27,28). In addition, motor development prompts cognitive development and there is a neuronal connection between systems for action and language perception (27,28). Thus, including motor movement training in a language intervention program might facilitate the process of language acquisition by enabling the child to manipulate objects and experience movements.
The authors were also determined to take advantage of specifically planned reinforcements from the therapist and parents especially when accompanied by their behavioral responses such as smiling or hugging, in order to facilitate the process of language acquisition in the child (25,29,30). The translated contents of the first stage, that is, "drilling and imitation" are illustrated in Table 1. Intervention process -Ask the mother or another care-giver to watch carefully.
-Repeat the word and point at the relevant picture/object. Repeat 2-3 times.
-Help the child point at the relevant picture/object.
-Repeat the process for 3 more words in this manner and reinforce each correct imitated response.
-Continue with 2 more words if the child has not learned the intervention procedure until he learns.
-Ask the mother or another care-giver to continue the intervention process at home, with 20 selected words, similar to what she has seen the therapist does.
-At the next visit, evaluate the child's performance -Refer the child to other specialists (audiologists or pediatric neurologists) for further evaluations if the child does not meet the indicators of success criterion at this stage.
-Continue to the next intervention stage if the child meets the success criterion.
Reinforcement techniques -First reinforcement of every correct response with edible prizes (food) until 4 correct imitated responses are encountered.
-Then, reinforcement of every 2 correct responses (fixed rate schedule). If the child does not meet the success criteria of any of the first 3 stages of training, the intervention will be discontinued at that stage and he or she will be referred to other specialists (audiologist, pediatric neurologists, pediatric psychiatrists, etc.)

Indicators of Success
for further evaluation and treatment, and if not able to proceed with the intervention stages again, the child will be referred to receive special training suitable for children with learning disabilities.
However, not being successful with the fourth and fifth stages, will lead the child to repeat an earlier stage as long as needed to accomplish the therapeutic objectives and to move forward. language disordered children (35,36). Moreover, the parents have an important role in continuation of the intervention process at home.

Discussion
The main aim of this study was to develop a Another language intervention protocol which mainly focused on language impaired children and was specifically concerned with morphology and pragmatics was developed and conducted (10). In spite of various cultural and linguistic differences in different countries and societies, this is a structured protocol with specific action pictures that encourage the child to find and generalize the correct responses and has attracted the attention and interest of many speech therapists all over the world. However, it is not produced based on the normal process of language acquisition in children.
Up to now, a number of language intervention protocols have been developed in Iran. One of the best ones is a guideline that was developed and